4 Types Of Constipation - Quick Explainer Guide

What is it: 

• Most common type of CC
• Characterized by muscles in the colon still functioning properly (not too fast or too slow) and bowel movements are at the right speed but still, your stool may be too hard or difficult to pass. 

Pathophysiology 

• Perceived difficulties with defecation

Diagnosis

• Rome III criteria 

What is it: 

• Characterized by reduced motility, delayed movement, of the stool through the large intestines due to an underlying dysfunction and abnormality of the colonic smooth muscle or neuropathy.
• This slow passage of waste through the large intestines leads to chronic health problems.

Pathophysiology 

• Can occur due to dysfunction of:
• Colonic smooth muscles activity
• Colocolonic reflexes
• Neurotransmitters
• Colonic pacemaker cell activity
• Decreased overall colonic motor activity
• Imparied or absent gastrocolonic responses 
• Decreased or absent sleep-wake motor activity
• Absent or abnormal number, amplitude, and velocity of high-amplitude propagated
• Loss of interstitial cells of Cajal
• Loss of enteric and cholinergic neurons (16)

Diagnosis

• No established criteria exists for its diagnosis

What is it: 

• Also known as dyssynergic defecation
• Characterized by the inability to correctly relax and coordinate the abdominal and anorectal muscles (pelvic floor muscles) to have a bowel movement. In other words, when everything is moving normal, at the normal pace through the large intestine, but have an inability or difficulty with stool evacuation from rectum with the final “push” for a BM (15).
• The feeling that you may still ‘need to go,’ resulting in constipation.

8 phenotypes of pelvic floor disorders have been recognized based on high resolution of manometric patterns, however only 4 subtypes have been described:

• Type I: adequate rectal push effort with paradoxical anal sphincter contraction
• Type II: inadequate rectal push effort with paradoxical anal sphincter contraction
• Type III: adequate rectal push effort but inadequate relaxation (<20%) of anal sphincter pressure
• Type IV: inadequate rectal push effort and also inadequate relaxation (<20%) of anal sphincter pressure (15)

Pathophysiology 

• ⅔ rds of patients acquire pelvic floor disorders during adulthood and the remainder have had it since childhood (15). In this case, it's likely the result of problematic childhood toilet habits. (LYG) 
• Inability to coordinate abdominal, rectoanal and pelvic floor muscles during defecation due to inadequate rectal and/or abdominal propulsive force, impaired anal relaxation (20% relaxation of basal resting pressure) or increased anal outlet resistance from paradoxical external anal sphincter or puborectalis contraction (15). 
• Pelvic floor disorders can be associated with a weak pelvic floor, rectocele, excessive perineal descent or solitary rectal ulcer syndrome (15). 
• Associated with delayed gastric emptying in 32% of individuals (15)
• Associated with rectal hyposensitivity in ⅔ rds of individuals (15)
• Structural abnormalities

• Rectal prolapse
• Rectal mucosal intussusception 
• Solitary rectal ulcer
• Rectocele - a collapse of the intestinal wall into the vagina (LYG)
• Symptoms: 
• Feeling like there is something coming down into your vagina (it may feel like you’re sitting on a small ball)
• Feeling or seeing a bulge in or coming out of your vagina
• Pressure or pain in your bottom
• Discomfort or numbness during sex (LYG)
• Enterocele
• Descending perineum syndrome
• Dyssynergic defecation
• Reduced perception of rectal filling
• Increased acuity of anorectal angle
• Failure of anal sphincter relaxation
• Paradoxical contraction of the anal sphincters
• Inadequate intrabdominal pressure
• Prolonged retention of stool in the retum
• Dysregulation of brain-gut axis with a lack of coordination between abdominal musculature, pelvic floor, and anorectal musculature

Diagnosis 

• Requires both symptoms and abnormal physiological tests for its diagnosis
• Proposed diagnostic criteria for dyssynergic defecation (15):

• Patients must satisfy the diagnostic bacteria for functional CC (Rome III) and
• Patients must have dyssynergic pattern of defecation (types I-IV), which is defined as a paradoxical increase in anal sphincter pressure (anal contraction) or less than 20% relaxation of the resting and sphincter pressure or inadequate propulsive forces based on manometry, radiological imaging or EMG.
• Patients must satisfy one or more of the following criteria:
• Inability to expel an artificial stool (50ml water-filled balloon) within 1 to 2 minutes.
• Inability to evacuate or >50% retention of barium during defecography

What is it: 

•  Combination of the above symptoms